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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': WORGROUND STORAGE TANK AGRAM �'"'� TANK PERMIT APPLICATION INFORMATION Y�N TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TAN . MARK ONLY 11 NEWPERMIT ❑3 RENEWALPERMIT L ,CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT / AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED CLOSED 1�I FACILITY/BITE NAME WHERE TANK IS INSTALLED: 7�� gr✓ V C FARM TANK.YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY •O A. OWNERS TANK IDN I B. MANUFACTURED BY: V, C. YEAR INSTALLED W D. TANK CAPACITY IN GALLONS: /,coo 11. TANK CONTENTS IF(A.i),IS MARKED,COMPLETE ITEM C.IF(Ai),IS NOT MARKED,COMPLETE ITEM 0. O CT[ A. ❑ 1 MOTOR VEHICLE FUEL ❑�,2 PETROLEUM B. C. ❑ 1 UNLEADED F-12 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT IJ ` OIL ❑ 1 PRODUCT ❑1 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑BO EMPTY ❑ 95 UNKNOWN F�2 WASTE ❑7 METHANOL f 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.N G(/ SDG.V C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ I WUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 01�95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ /SECONDARY CONTAINMENT ❑99 OTHER B.TANK ❑ 1�EUI� ❑2 STAINLESS STEEL 3 FIBERGLASS ❑/STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 2 R ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM a IOD%MMmOLCOMPATIBLEFRP 9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 AIKYDUNING ❑3 EPOKYUNING ❑/PHFNOUCUNING LINING ❑ 5 GLASS UNING ❑6 UNLINED UNKNOWN ❑ISUNINGMATERIAL COMPATIBLE WITH IDO%MERIANOL7 ❑YES ❑NO OTHER D.CORROSION ❑ 7 POLYETHLBTE WRAP ❑2 TAA OR ASPHALT ❑3 VI WMP ❑/FIBERGLASS REINFORCED PJSTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNNN0IAN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A V I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A V 1 FIBEflGU$S PIPE A U 91 NONE PIt C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A' U 7 STEEL CUD W/FRP A U B IOD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER _ V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 1(AT P S I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED OUANTITY OF SUBSTANCE REMAINING IN GALLONS U. WAS TANK FILLED WITH INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE 1 LOCAL AGENCY USE ONLY UNTYN JURISDICTION AGENCY N FACILITY IDR TANK ID N Q� E�� CURB'F LOCAL AGENCY FACILITY 101 APPROVED BY NAME PHONE I WITH AREA CODE Ij L FD v 15 Z127- PEPMtTNIUMMBEFI PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECKI PERMIT AMOUNT SURCHARGE AMT. FEE COO! RECEIPT N BY: T FORM B(629-88) THIS FORM MUST BE ACCOYPANIE FACILITY/STIE APPLICATION, FORM 'A',UNLESS A eWENT FORMA' HAS BEEN FILED ��. DATA PROCF.SSINr /Olno